Low Risk for Intra Abdominal Trauma
We have discussed pediatric trauma several times within the PedEM Morsels (Splenic Injury, Head Injury, Pneumothorax, etc), because it is often a source of trepidation, confusion and concern. This often leads to over-reliance on ionizing radiation to help alleviate concern. Naturally, this is not without its problems (Medical Radiation). Is there a way to help define a group of kids who are at Low Risk for Intra Abdominal Trauma?
Pediatric Trauma- Why We Care:
- Unintentional Injuries are leading cause of mortality in children.
- Over the past decade, the injury death rate for children in the US decreased ~30% (in 2000, the #of Deaths = 12,441!); however, more than 9,000 children died from accidental injuries in 2009… still the #1 cause of Mortality for children.
- 9,000 deaths > 8,760 hours/yr.
- Every hour, ~one child DIES from an injury!
- Every 4 seconds, a child is treated in an Emergency Department for an injury!
- The US child injury death rate is among the worst of all high-income countries.
- Traumatic brain injury (TBI) and thoracic trauma are the leading causes of mortality and morbidity.
- While abdominal trauma is third most common it is the number one initially unrecognized cause of death.
Kids can be Tricky:
- Development Matters
- The pediatric population includes a spectrum of developmental stages, each associated with its own unique challenges.
- Communication issues can confound evaluation and diagnosis.
- Fear / apprehension can confound history and exam.
- Immature children may lack the motor control to adequately protect themselves.
- Older children may expose themselves to high risk situations by making ill-advised decisions.
- Anatomy Matters
- Potential for significant injuries due to less protection.
- Relatively larger organs to body size increase risk of injury.
- Abdominal wall musculature less protective of intra-abdominal structures.
- Chest wall is very compliant
- Does not dissipate applied forces, transmitting that force to the underlying structures more readily.
- Increases work of breathing, especially with underlying injured lung.
- Bladder is an intra-abdominal organ in young children, making it more vulnerable.
- Kidneys are positioned more inferiorly, exposing them to injury.
- Elastic and resilient tissues may not demonstrate external signs of trauma.
- Physiology Matters
- Metabolic rate is increased.
- Even when not stressed, kids consume oxygen at >2 times adult rate.
- Have less Function Residual Capacity (less of a reservoir of oxygen).
- Will desaturate rapidly.
- Cardiac output is dependent upon preload and heart rate.
- Will increase heart rate to augment cardiac output, rather than increase contractility.
- Conditions that adversely effect preload (tension pneumothorax, tamponade) will not be tolerated well.
- Compensate for hypovolemia / hemorrhage very well.
- Can maintain blood pressure even up to 30+% blood volume loss.
- Hypotension is a late clinical indicator of hemorrhage.
- Metabolic rate is increased.
Radiation is Not Without Risk:
- Even though the evaluation of children can be challenging, this challenge should not be met with ordering a multitude of CT scans.
- See PedEM Morsel Medical Radiation.
- Intellectual development is adversely affected when infant brain is exposed to ionizing radiation. [Mathews, 2013].
- CT Scans during childhood and adolescence are followed by an increase in cancer incidence (not yet determined to be a causal relationship and may, in fact, represent reverse causation). [Miglioretti, 2013]
Low Risk for Intra-Abdominal Injury
- Clinical prediction rule may rule out intra-abdominal injury requiring acute intervention in children with blunt torso trauma [Holmes, 2013]
- Based on derivation cohort study without independent validation
- 12,044 children (median age 11.1 years) with blunt torso trauma
- 761 had intra-abdominal injury, 26.7% received acute interventions
- Acute interventions = therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or IV fluid for ≥ 2 nights for pancreatic/gastrointestinal injuries
- Sensitivity 97%; Specificity 42.5%
- Prediction rule based on factors not requiring acute intervention:
- No evidence of abdominal wall trauma or seat belt sign
- Glasgow Coma Scale score > 13
- No abdominal tenderness
- No evidence of thoracic wall trauma
- No complaints of abdominal pain
- No decreased breath sounds
- No vomiting
- The abdominal exam is useful!
- Risk of intra-abdominal injury increased as degree of abdominal findings increased.
- Either abdominal tenderness OR abdominal pain in isolation are associated with non-negligible risk and warrants evaluation.
- Isolated abdominal tenderness or pain = 8% had intra-abdominal injury
- Isolated abdominal pain = 3 % had intra-abdominal injury.
- GCS affects sensitivity of abdominal tenderness.
- GCS 15 – abdominal tenderness sensitivity = 79%
- GCS 14 – abdominal tenderness sensitivity = 57%
- GCS 13 – abdominal tenderness sensitivity = 37%
- Seat Belt Sign matters
- Seat Belt Sign is associated with increased risk for intra-abdominal injury, particularly hollow viscus or mesenteric injury.
- Seat Belt Sign without pain or tenderness had lower risk for injury, but still warrant evaluation.
- Evaluation for possible Intra-Abdominal Injury does not necessarily equal CT Scan.
- Further risk stratification can be done via:
- Serial Exams and Observation (my personal preference… in addition to U/S)
- Bedside Ultrasound
- Laboratory studies
- AST > 200 U/L
- ALT > 125 U/L
- Hematuria (>5 RBCs / HPF)
- Initial Hematocrit < 30%
- Further risk stratification can be done via:
Adelgais KM1, Kuppermann N2, Kooistra J3, Garcia M4, Monroe DJ5, Mahajan P6, Menaker J7, Ehrlich P8, Atabaki S9, Page K10, Kwok M11, Holmes JF12; Intra-Abdominal Injury Study Group of the Pediatric Emergency Care Applied Research Network (PECARN). Accuracy of the abdominal examination for identifying children with blunt intra-abdominal injuries. J Pediatr. 2014 Dec;165(6):1230-1235. PMID: 25266346. [PubMed] [Read by QxMD]
Borgialli DA1, Ellison AM, Ehrlich P, Bonsu B, Menaker J, Wisner DH, Atabaki S, Olsen CS, Sokolove PE, Lillis K, Kuppermann N, Holmes JF; Pediatric Emergency Care Applied Research Network (PECARN). Association between the seat belt sign and intra-abdominal injuries in children with blunt torso trauma in motor vehicle collisions. Acad Emerg Med. 2014 Nov;21(11):1240-8. PMID: 25377401. [PubMed] [Read by QxMD]
Holmes JF1, Lillis K, Monroe D, Borgialli D, Kerrey BT, Mahajan P, Adelgais K, Ellison AM, Yen K, Atabaki S, Menaker J, Bonsu B, Quayle KS, Garcia M, Rogers A, Blumberg S, Lee L, Tunik M, Kooistra J, Kwok M, Cook LJ, Dean JM, Sokolove PE, Wisner DH, Ehrlich P, Cooper A, Dayan PS, Wootton-Gorges S, Kuppermann N; Pediatric Emergency Care Applied Research Network (PECARN). Identifying children at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med. 2013 Aug;62(2):107-116. PMID: 23375510. [PubMed] [Read by QxMD]
Nishijima DK1, Yang Z, Clark JA, Kuppermann N, Holmes JF, Melnikow J. A cost-effectiveness analysis comparing a clinical decision rule versus usual care to risk stratify children for intraabdominal injury after blunt torso trauma. Acad Emerg Med. 2013 Nov;20(11):1131-8. PMID: 24238315. [PubMed] [Read by QxMD]
Miglioretti DL1, Johnson E, Williams A, Greenlee RT, Weinmann S, Solberg LI, Feigelson HS, Roblin D, Flynn MJ, Vanneman N, Smith-Bindman R. The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA Pediatr. 2013 Aug 1;167(8):700-7. PMID: 23754213. [PubMed] [Read by QxMD]
Mathews JD1, Forsythe AV, Brady Z, Butler MW, Goergen SK, Byrnes GB, Giles GG, Wallace AB, Anderson PR, Guiver TA, McGale P, Cain TM, Dowty JG, Bickerstaffe AC, Darby SC. Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ. 2013 May 21;346:f2360. PMID: 23694687. [PubMed] [Read by QxMD]
Holmes JF1, Mao A, Awasthi S, McGahan JP, Wisner DH, Kuppermann N. Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma. Ann Emerg Med. 2009 Oct;54(4):528-33. PMID: 19250706. [PubMed] [Read by QxMD]
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Very good. Deep thinking and nicely presented.
Lecture Notes Usmle Step 1 2014 US printed
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